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About
| Skincare Tips |
Client Consult Forms |
Pre/Post Care Procedure |
Contact Us
About Us
Skincare Tips
Client Consult Forms
Pre/Post Care Procedure
Contact Us
About Us
Skincare Tips
Client Consult Forms
Pre/Post Care Procedure
Contact Us
Medical Aesthetics
MORPHEUS8
Lumecca by Inmode
Microneedling
Skin Pen
Facial Peels
VI Peel
Glycolic Acid Peel
Botox
Personalized Skincare
Facials
Anti-Aging Facial
European Facials
Facial Treatments
Acne Facials
Microdermabrasion Facial
LED Facial
Intense Pulse Light Therapy
Permanent Makeup
Microdermabrasion
Dermaplane
Hydrojelly Mask
HydraFacial
HydraFacial Customization
HydraFacial Scalp Treatment
HydraFacial Technology
Diamond Tip Microdermabrasion
Brows and Lashes
Eyebrow Henna
Eyelash Lift & Tint
GIFT CERTIFICATES
FAQ
Collaborate With Us
Medical Aesthetics
MORPHEUS8
Lumecca by Inmode
Microneedling
Skin Pen
Facial Peels
VI Peel
Glycolic Acid Peel
Botox
Personalized Skincare
Facials
Anti-Aging Facial
European Facials
Facial Treatments
Acne Facials
Microdermabrasion Facial
LED Facial
Intense Pulse Light Therapy
Permanent Makeup
Microdermabrasion
Dermaplane
Hydrojelly Mask
HydraFacial
HydraFacial Customization
HydraFacial Scalp Treatment
HydraFacial Technology
Diamond Tip Microdermabrasion
Brows and Lashes
Eyebrow Henna
Eyelash Lift & Tint
GIFT CERTIFICATES
FAQ
Collaborate With Us
Book Now
VI Peel Client Consult Form
VI Peel Form
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Patient Name
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Date
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Email
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Phone
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The VI Peel® contains a synergistic blend of powerful ingredients suitable for all skin types. VI Peel® will improve the tone, texture and clarity of the skin; reduce age spots, improve hyperpigmentation (including melasma), soften lines and wrinkles; clear acne skin conditions; reduce or eliminate acne scars; and stimulate the production of collagen, for firmer, more youthful skin.
Contraindications:
Patients who are pregnant or who are breast feeding
Patients who have an aspirin, hydroquinone or phenol allergy
Patients who have used oral isotretinoin (Accutane) within the past 6 months
Patients who have active cold sores, warts, open wounds or history of herpes simplex
Patients who are undergoing chemotherapy and or radiation therapy within 6 months
Patients with a history of an autoimmune (i.e. Lupus) or liver disease/disorder as well as any condition that may weaken their immune system
Consent
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Prior to receiving treatment I have communicated with the Practitioner about any conditions or medications that may contraindicate this procedure.
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Consent
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I understand that there may be some degree of discomfort such as burning, stinging, redness, heat or tightness during and a week after the procedure.
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Consent
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I understand that there is no guarantee of the final results of the peel. Occasionally hyperpigmentation may develop which may persist for a week or months after the peel.
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Consent
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I understand although complications are very rare, sometimes they may occur. In the event of any complications, I will immediately contact the Physician/Clinician who performed the treatment.
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Consent
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I understand if I have any acne condition in the skin, the peel may bring out oils and bacteria from below the surface and can cause an actual breakout.
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Consent
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I understand that maintenance of VI Peel® treatments are necessary to maintain results as well as the recommended VI Derm® skin care regimen and SPF 50+.
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Consent
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I understand the extended direct sun exposure including tanning beds are strictly prohibited before and after receiving the VI Peel®.
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Consent
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I understand no activities involving excessive sweating can be done for 72-96 hours (exercise, sauna, hot tub steam room and that overheating may cause me to develop blisters or cause hyperpigmentation to worsen.)
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Consent
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I understand that I must protect my skin with VI Derm® SPF 50+and avoid sun exposure during the 7 day exfoliation process.
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Consent
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I understand that this is an elective cosmetic procedure.
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Consent
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I understand that no other
chemical peels
, facial machine brushes or medical device (laser, IPL, etc) treatments may be performed on my skin until my physician/clinician releases me to do so. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.
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Printed Patient Name
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Patient Signature
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Date
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MM slash DD slash YYYY
Printed Practitioner Name
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Practitioner Signature
Date
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MM slash DD slash YYYY
PEEL TYPE:
LOT #
EXP DATE:
MM slash DD slash YYYY
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